Hillcrest Health Care Center: Care Plan Failures - IA
Inspectors found that wasn't happening.
A federal complaint inspection completed October 8, 2025 cited the facility under F0657, a deficiency tied to the accuracy and completeness of care planning. The level of harm was recorded as minimal harm or potential for actual harm. A few residents were affected.
The citation is narrow in scope. But what it describes is a facility that wrote its own rules for what to do after a resident falls and then didn't follow them.
Falls are among the most serious and common risks in nursing home care. For an older adult, a fall can mean a broken hip, a head injury, or a rapid decline. The protocols Hillcrest put in writing exist precisely because a fall is not a self-contained event. It is a signal. It raises questions about whether a resident's medications need adjustment, whether their environment needs to change, whether their care plan reflects who they actually are and what they actually need right now. The 72-hour monitoring window exists because some injuries, particularly internal ones, do not announce themselves immediately.
When a facility skips the physician call, the family notification, the follow-up monitoring, the root cause review, and the care plan update, it is not a paperwork problem. It is a gap in the chain of decisions that protects a person who has already been hurt once from being hurt again.
Hillcrest's own policy required the interdisciplinary team to review every fall investigation and document its findings and recommendations in the resident's clinical record. That step closes the loop. It is how a facility learns whether a pattern is developing, whether one resident is falling repeatedly in the same location, whether a particular shift or a particular time of day keeps appearing in the incident reports. The Risk Committee was supposed to be the final check, analyzing trends and deciding whether further intervention was warranted.
Inspectors found those steps weren't being completed.
The facility's fall policy, as described in the inspection record, is not a vague aspiration. It is a numbered, sequential protocol. Notify the physician and representative. Complete 72-hour follow-up documentation. Conduct a fall risk evaluation. Investigate probable causal factors. Review with the interdisciplinary team. Document in the clinical record. Update the care plan. Analyze trends through the Risk Committee. Eight steps. Each one exists because someone, at some point, recognized that skipping it left a resident more vulnerable.
The citation does not identify the residents by name or describe their specific injuries or outcomes. It does not say how many falls were involved or over what period of time. What it says is that the facility's own required process was not being carried out, and that a few residents were affected.
For the residents and families at Hillcrest, the question left open by this inspection is a simple one: after someone fell, did anyone call? Did anyone check back the next day, and the day after that? Did anyone sit down and ask why it happened and whether the care plan needed to change?
The inspection record does not answer that.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hillcrest Health Care Center from 2025-10-08 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 11, 2026 · Our methodology
Hillcrest Health Care Center in Hawarden, IA was cited for violations during a health inspection on October 8, 2025.
Inspectors found that wasn't happening.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.